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Arch Ophthalmol. 2003;121:132-133.

Of people older than 50 years, 0.6% have geographic atrophy (GA); and of those 75 years or older, 3.5% have GA.¹ Geographic atrophy is bilateral in up to 56% of cases,² and severe visual loss occurs in up to 42% of eyes.¹ In comparison, severe visual loss occurs in 0.03% and 48% of eyes with early nonneovascular age-related macular degeneration (AMD) and neovascular AMD, respectively.¹ Macular translocation with 360° peripheral retinectomy (MT360), originally designed for neovascular AMD,³ rotates the retina away from a subretinal lesion onto healthy retinal pigment epithelium, restoring visual function.^4-5 We report a case of GA secondary to end-stage nonneovascular AMD treated with MT360.

Report of a Case
A 68-year-old man had a 2-month history of blurred vision in the right eye. His ophthalmic history included long-standing reduced visual acuity in the left eye, amblyopia in the left eye, and bilateral pseudophakia. An ocular examination revealed a best-corrected visual acuity of 20/100 OD and 20/64 OS for distance (Early Treatment Diabetic Retinopathy Study protocol) and 20/50 OD and 20/40 OS for near, bilateral silicone posterior chamber intraocular lenses, and bilateral GA surrounding the fovea, measuring 4 Macular Photocoagulation Study disc areas (Figure 1A). Fluorescein angiography confirmed the absence of choroidal neovascularization in the right eye (Figure 1B).

View larger version (32K): [in this window] [in a new window] Figure 1. Preoperative fundus photograph and fluorescein angiography of the right eye. A, An area of geographic atrophy measuring 4 Macular Photocoagulation Study disc areas, involving the fovea (arrowheads). The inferior edge of the lesion is highlighted (arrow). B, A late angiographic frame does not show any evidence of choroidal neovascularization.

An MT360 was performed and involved pars plana vitrectomy with vitreous base shaving, total retinal detachment by subretinal injection of balanced salt solution plus, a 360° peripheral retinectomy, and superior retinal rotation with a modified diamond-dusted soft-tipped cannula (Synergetics Inc, St Charles, Mo).⁵ After foveal placement over normal retinal pigment epithelium and retinal tamponade with perfluorocarbon liquid, endolaser retinopexy was performed at the posterior margin of the retinectomy and a silicone/polymethyl methacrylate lens exchange was performed, followed by direct perfluorocarbon liquid/silicone oil exchange.⁵ Three weeks later, the patient underwent superior oblique tenotomy, inferior oblique transposition, lateral rectus resection with transposition, and silicone oil removal.⁵

The best-corrected visual acuity was 20/80 OD at 4 weeks and 20/32 OD at 2 and 6 months. Near visual acuity with a +2.50-diopter (D) add was 20/20 OD at 2 and 6 months. The patient had diplopia controlled with a 20-D base-out prism without perceived tilt. Right funduscopy demonstrated a translocated fovea overlying healthy retinal pigment epithelium with no evidence of atrophic changes, choroidal neovascularization, or retinal detachment (Figure 2A and B).

View larger version (50K): [in this window] [in a new window] Figure 2. Postoperative fundus photograph and fluorescein angiography of the right eye. A, The patient is fixating on the camera's fixation marker. The superiorly translocated retina is overlying healthier retinal pigment epithelium (RPE), and the previously noted area of RPE atrophy is seen inferiorly (arrowheads). The inferior edge of the lesion is highlighted (arrow). B, A middle angiographic frame confirms that the translocated retina is overlying healthier RPE.

Comment
A small GA lesion treated with limited macular translocation has been reported.⁶ The 4 Macular Photocoagulation Study disc areas of atrophy seen in this case required more foveal shift than the typical 1200-µm rotation achieved with limited macular translocation, which can be unpredictable. An MT360 can rotate the retina up to 80°, and the postoperative retinal position is predictable.^3-4 Complications of MT360 include retinal detachment with proliferative vitreoretinopathy, cystoid macular edema, macular pucker, diplopia, and cyclotropia.^4-5 Full visual rehabilitation after MT360 also requires silicone oil removal and strabismus surgery.^4-5

Because of photoreceptor and retinal pigment epithelial degeneration, retinal translocation would not be expected to improve visual function in long-standing cases of GA.⁷ In contrast, 50% of eyes with early GA and good vision have reduced contrast sensitivity and reading rates secondary to parafoveal scotomata.⁷ Eyes with GA and recent visual loss, or reduced visual function with good central vision, may benefit from MT360 before severe foveal photoreceptor degeneration occurs. However, the potential for visual recovery must be weighed against the sight-threatening complications associated with this surgery. A case-control study may be warranted to investigate the treatment of these selected cases of end-stage nonneovascular AMD with MT360.

We thank John T. Harriott, MD, Winston-Salem, NC, for his referral of the patient, his thoughtful input, and his assistance with the care of the patient.

Mark T. Cahill, FRCOphth; Sharon F. Freedman, MD; Cynthia A. Toth, MD
Durham, NC

Corresponding author: Cynthia A. Toth, MD, Duke University Eye Center, Room 107, Erwin Road, PO Box 3802, Durham, NC 27710 (e-mail: info{at}dukeeye.org).

REFERENCES
1. Klein R, Wang Q, Klein BEK, Moss SE, Meuer SM. The relationship of age-related maculopathy, cataract and glaucoma to visual acuity. Invest Ophthalmol Vis Sci. 1995;36:182-191. FREE FULL TEXT 2. Wang JJ, Mitchell P, Smith W, Cumming RG. Bilateral involvement by age related maculopathy lesions in a population. Br J Ophthalmol. 1998;82:743-747. FREE FULL TEXT 3. Machemer R, Steinhorst UH. Retinal separation, retinotomy, and macular relocation, II: a surgical approach for age-related macular degeneration? Graefes Arch Clin Exp Ophthalmol. 1993;231:635-641. FULL TEXT | ISI | PUBMED 4. Eckardt C, Eckardt U, Conraf HG. Macular rotation with and without counter-rotation of the globe in patients with age-related macular degeneration. Graefes Arch Clin Exp Ophthalmol. 1999;237:313-325. FULL TEXT | ISI | PUBMED 5. Toth CA, Freedman SF. Macular translocation with 360-degree peripheral retinectomy impact of technique and surgical experience on visual outcomes. Retina. 2001;21:293-303. FULL TEXT | ISI | PUBMED 6. Benner JD, Sunness JS, Ziegler MD, Soltanian J. Limited macular translocation for atrophic maculopathy. Arch Ophthalmol. 2002;120:586-591. FREE FULL TEXT 7. Sunness JS, Rubin GS, Applegate CA, et al. Visual function abnormalities and prognosis in eyes with age-related geographic atrophy of the macula and good visual acuity. Ophthalmology. 1997;104:1677-1691. ISI | PUBMED

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ABSTRACT | FULL TEXT